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Associations between Birth Health,

Maternal Employment, and Child Care
Arrangement among a Community
Sample of Mothers with Young Children
a b c
Chi Chiao , Laura Chyu & Kate Ksobiech
a
Institute of Health and Welfare Policy and Research Center for
Health and Welfare Policy, College of Medicine, National Yang-Ming
University , Taipei , Taiwan
b
Northwestern Cells to Society Center on Social Disparities
and Health at the Institute for Policy Research, Northwestern
University , Evanston , Illinois , USA
c
Department of Communication , University of Wisconsin-
Whitewater , Whitewater , Wisconsin , USA
Published online: 04 Nov 2013.

To cite this article: Chi Chiao , Laura Chyu & Kate Ksobiech (2014) Associations between Birth Health,
Maternal Employment, and Child Care Arrangement among a Community Sample of Mothers with
Young Children, Social Work in Public Health, 29:1, 42-53, DOI: 10.1080/19371918.2011.619465

To link to this article: http://dx.doi.org/10.1080/19371918.2011.619465

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 Social Work in Public Health, 29:42–53, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 1937-1918 print/1937-190X online
DOI: 10.1080/19371918.2011.619465

Associations between Birth Health, Maternal

Employment, and Child Care Arrangement among a
Downloaded by [Queensland University of Technology] at 10:56 21 November 2014

Community Sample of Mothers with Young Children

Chi Chiao
Institute of Health and Welfare Policy and Research Center for Health and Welfare Policy,
College of Medicine, National Yang-Ming University, Taipei, Taiwan

Laura Chyu
Northwestern Cells to Society Center on Social Disparities and Health at the Institute for
Policy Research, Northwestern University, Evanston, Illinois, USA

Kate Ksobiech
Department of Communication, University of Wisconsin-Whitewater, Whitewater,
Wisconsin, USA

Although a large body of literature exists on how different types of child care arrangements affect
a child’s subsequent health and sociocognitive development, little is known about the relationship
between birth health and subsequent decisions regarding type of nonparental child care as well
as how this relationship might be influenced by maternal employment. This study used data from
the Los Angeles Families and Neighborhoods Survey (L.A.FANS). Mothers of 864 children (ages
0–5) provided information regarding birth weight, maternal evaluation of a child’s birth health,
child’s current health, maternal employment, type of child care arrangement chosen, and a variety
of socioeconomic variables. Child care options included parental care, relative care, nonrelative care,
and daycare center. Multivariate analyses found that birth weight and subjective rating of birth health
had similar effects on child care arrangement. After controlling for a child’s age and current health
condition, multinomial logit analyses found that mothers with children with poorer birth health are
more likely to use nonrelative and daycare centers than parental care when compared to mothers with
children with better birth health. The magnitude of these relationships diminished when adjusting
for maternal employment. Working mothers were significantly more likely to use nonparental child
care than nonemployed mothers. Results suggest that a child’s health early in life is significantly
but indirectly related to subsequent decisions regarding child care arrangements, and this association
is influenced by maternal employment. Development of social policy aimed at improving child care
service should take maternal and family backgrounds into consideration.

Keywords: Child care arrangement, birth health, maternal employment, socioeconomic factors

Address correspondence to Chi Chiao, Institute of Health and Welfare Policy, National Yang-Ming University, No.
155, Sec. 2, Li-nong St., 112, Taipei, Taiwan. E-mail: cchiao@ym.edu.tw

42
 BIRTH HEALTH AND CHILD CARE ARRANGEMENT 43

INTRODUCTION

Over the past few decades, women’s participation in the labor force has increased dramatically. As
a result, the number of children who have working mothers has also increased (Hofferth, 1996; U.S.
Bureau of Labor Statistics, 2010). Women’s employment, combined with changes in family struc-
ture and parents’ desires to provide their children with educational and social experiences in struc-
tured settings, has led to a substantial increase in demand for and use of non-parental child care.
A large body of literature examines how non-parental child care settings often affect young
children’s health as well as their social and cognitive development (Bianchi & Milkie, 2010).
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These studies are largely based on the epidemiological argument that increased person-to-person
contact in such settings elevates the risks of acquiring a communicable disease. Studies have
documented a higher rate of acute infectious diseases such as hepatitis A, diarrhea, various
respiratory conditions, and meningitis for children attending daycare centers when compared
to those being cared for at home, even after controlling for sociodemographic characteristics
(Alexander, Zinzeleta, Mackenzie, Vernon, & Markowitz, 1990; Bradley, 2003; Fleming, Cochi,
Hightower, & Broome, 1987; Gordon, Kaestner, & Korenman, 2007; Haskins & Kotch, 1986; Lu
et al., 2004; Presser, 1988). While these studies establish a clear association between the type
of child care arrangement utilized and a child’s subsequent health, the causal link between these
variables has yet to be demonstrated. The present study examines type of child care arrangement
utilized as a dependent rather than an independent variable, suggesting that a mother’s evaluation
of her child’s health, as well as a child’s birth weight, might well influence her subsequent choice
of child care arrangement.
Little research has been done on how birth weight and a mother’s perception of her child’s health
influence her decisions on child care. In contrast, there are many studies focused on the effects
of maternal employment on children’s health and psychosocial development (Baydar & Brooks-
Gunn, 1991; Brooks-Gunn, Han, & Waldfogel, 2002; Gennetian, Hill, London, & Lopoo, 2010;
Nomaguchi, 2006; Vandell et al., 2010). In order to balance work and child care responsibilities,
employed mothers often use child care regardless of the child’s health status. We hypothesize that
a child’s age, maternal socioeconomic status (SES), and family situation may affect the association
between a child’s health at birth and parental decisions regarding child care.
Poorer birth health is perhaps less of an issue for older children using child care due to the
relative maturity of their immune systems when compared to younger children (Joesch, Maher,
& Durfee, 2006). Higher maternal SES is associated with better health at birth (Fleming et al.,
1987; Kleinman & Kessel, 1987; Collins & Schulte, 2003; Martin et al., 2003). Racial/ethnic
disparities in adverse birth circumstances, such as preterm delivery and low birth weight, persist
after controlling for maternal SES (Collins & David, 1990; Kleinman & Kessel, 1987). Mothers
without a cohabiting partner to aid in childrearing may have to use child care regardless of the
child’s health status in order to balance work and child care responsibilities. Moreover, family
income may well influence the relationship with certain types of child care arrangements (e.g.,
licensed child care), perhaps only possible when family income is large enough to make such
choices affordable (Bianchi & Milkie, 2010).
The work-family conflict model (Bianchi & Milkie, 2010; Goode, 1960; Kelly & Voydanoff,
1985; Warren & Johnson, 1995) provides a comprehensive framework that takes into account the
broader context in which women live and work. The model places working women in a broader
context by examining potential incompatibility between work and family responsibilities such as
motherhood. This study thus hypothesizes that a child’s health status at birth, as perceived by the
mother, is temporally antecedent to subsequent decisions regarding child care arrangements. This
relationship may be explained in part by maternal employment, which, in turn, is associated with
choice of child care arrangement. To test these hypotheses, two specific research questions were
investigated: (1) Does a child’s health (i.e., birth weight and maternal assessment of newborn’s
 44 C. CHIAO ET AL.

perceived overall health) at birth affect decisions about child care arrangements, after adjusting for
the child’s current health and demographic characteristics? and (2) To what extent does maternal
employment account for the variation in the relationship between a child’s health at birth and
the selection of a particular child care arrangement, after controlling for maternal SES and child
characteristics? In contrast to synthetic concerns as suggested by the Health Belief Model (Becker
& Rosenstock, 1987), the probability that a mother will place her child in center care to avoid a
health consequence depends on how serious she considers the consequence of poor birth health.
That is, perceived susceptibility to illness, as a consequence of poor health at birth, may well be
associated with a mother’s choice of child care arrangement.
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This study contributes to the understanding of the relationship between child care arrangement,
child health and maternal employment in two important ways. First, it investigates the temporal
relationship between perceived birth health and subsequent child care arrangement while con-
trolling for a child’s current health status. Second, by including a sizable number of mothers of
disadvantaged SES in a representative sample from Los Angeles County in analyses, this study
assesses the generalizability of findings of previous studies on ethnic minority and low income
families regarding child care choices.

METHOD

Data
This study analyzed data from Wave 1 of the Los Angeles Family and Neighborhood Survey
(L.A.FANS). The study was specifically designed to examine family choices regarding their neigh-
borhoods and the impact of such neighborhood and family choices on the development of their
children. From a sample of 65 neighborhoods (defined by census tract) from the 1,652 census tracts
in Los Angeles County, the L.A.FANS used sampling procedures to yield a sample of 3,010 house-
holds that was representative of the Los Angeles County population. Further details on the sam-
pling process are available through L.A.FANS (Sastry, Ghosh-Dastidar, Adams, & Pebley, 2003).
The present study is based on data collected from a random sample of households in each of
the 65 census tracts that had at least one child (0–5 years of age) who was not yet enrolled in
school. If that child had one or more siblings 5 years of age or less living in the same household,
they were also included in the study. There were 714 (66%) households with one child in the
defined age range and 372 (34%) additional siblings in that same age range for a total of 1,086
children. Each child’s primary caregiver (generally the mother) was interviewed to gather data on
birth weight, child’s perceived health at birth, child’s current health, type of child care utilized,
and basic social and demographic information. Data were obtained for 887 children for a response
rate of 81.6%. Of these 887 children, 23 were enrolled in Head Start. Because Head Start users
are typically distinct in terms of lower education and income for the households in question, those
23 children were excluded from this study, yielding an effective sample size of 864.

Measures
The outcome variable used in the analysis was type of child care arrangement subsequently chosen
by the parents, a categorical measure, assessed by asking mothers whether or not the child was in
nonparental child care during the four weeks before the interview and primary type of care used.
Primary nonparental care was further categorized into three types: relative care, nonrelative care,
and center-based care (Hofferth & Wissoker, 1992; Gordon & Chase-Lansdale, 2001; NICHD
Early Child Care Research Network, 1997). Non-relative care was care provided by a regular
babysitter, maid, nanny, au pair, neighbor or friend, and could take place in the child’s or the
 BIRTH HEALTH AND CHILD CARE ARRANGEMENT 45

provider’s home. Center-based care included day care centers, nursery schools and preschools. In
our sample, parental child care was chosen by 62%; relative care by 15%; nonrelative care by
10%, and center care by 13%.
The major explanatory variables were birth weight and the mother’s subjective evaluation of
child’s health at birth. Birth weight was reported by the mother and coded dichotomously: low
birth weight (less than 2,500 grams) and not low birth weight (2,500 grams or greater). Subjective
evaluation of birth condition was based on mothers’ response to the question: “Compared to other
babies in general, would you say that your child’s health at birth was better, the same, or worse
than other babies?” Responses were categorized as better, same or worse. To estimate the effect
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of birth health while controlling for a child’s current health situation, questions were included to
assess the child’s current health condition and the child’s demographic characteristics. Frequency
of ear infections during the past year was used as a proxy for child’s health (Eldeirawi et al.,
2010; Hardy & Fowler, 1993; Tallow, Repetti, & Seeman, 1980); this measure was dichotomized
into “poorer” current health condition (more than 3 ear infections per year) or “better” current
health condition (3 or less). Child’s age was categorized as newborn (less than 1 year old), infant
(1–2 years), or toddler (3–5 years) based on physical and cognitive developmental stages.
Another important explanatory variable was maternal employment status. Mothers were cate-
gorized as: not working, working 1–34 hours per week, and working 35 or more hours per week.
Other background variables used in the analyses were mother’s education, race/ethnicity, family
income and marital status. Mother’s education was categorized as less than high school, high
school graduate, more than high school or college graduate and above. Mother’s race/ethnicity
was categorized as self-reported White, Black, Hispanic, or Asian/Pacific Islander. Marital status
was indexed as married, not married and cohabiting, or not married and not cohabiting. Annual
family income was based on quartile distribution: less than $5,000; $5,000–20,000; $20,000–
40,000; and >$40,000.

Analytical Strategies
This study uses STATA version 8.2 (Stata, 2004) to conduct analyses on how children’s health
at birth, as measured by parental subjective evaluation and reported birth weight, affects parents’
decisions regarding type of nonparental child care utilized, while adjusting for the child’s cur-
rent health, maternal employment, and other sociodemographic characteristics. Analyses include
bivariate tabulations that characterized the distribution of sociodemographic characteristics of the
sample population by birth health outcomes. Then, using multinominal logit models, we explored
whether maternal employment and individual sociodemographic variables affected the relationship
between birth health condition and subsequent choices regarding child care arrangement.
Progressive model adjustment examined the significance of hypothesized associations and the
influence of maternal employment on the association. The first model included data on the child’s
current health and current age to address the effects of health at birth on subsequent child care
arrangement chosen while controlling for both current health and age. The second model added
maternal employment, maternal education, marital status, and family income. All analyses were
conducted separately for birth weight and subjective rating of child’s birth health. These analyses
were weighted and standard errors adjusted to account for the complex sample design.

RESULTS

Table 1 provides descriptive statistics stratified by birth health conditions. Overall, children with
low birth weight (LBW; n D 57) were significantly more likely to receive nonparental care than
 46 C. CHIAO ET AL.

TABLE 1
Percentage Distribution for Child Care Choice and Socioeconomic Characteristics
by Birth Health Status at Birth, L.A.FANS

Subjective Rating of
Birth Weight Birth Health
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< 2,500 Grams > 2,500 Grams Better Same Worse Total

Child Care Choice

Use of nonparental child care
No 47.06 63.13 54.92 65.64 56.84 61.91
Relative care 5.74 16.21 18.13 14.97 9.44 15.42
Nonrelative care 23.10 8.88 9.31 8.66 22.27 9.95
Center care 24.10 11.78 17.63 10.73 11.45 12.71
Child’s Characteristics
Age of child
Less than 1 year old 13.72 17.18 19.34 17.31 6.58 16.92
1–2 years old 28.03 41.54 37.29 40.97 47.58 40.52
3–5 years old 58.24 41.28 43.37 41.71 45.84 42.56
Current health condition
(freq of ear infections)
Better (< 3 ear infections) 81.76 87.29 86.66 88.54 74.38 86.87
Poorer ( 3 ear infections) 18.24 12.71 13.34 11.46 25.62 13.13
Maternal Socioeconomic Characteristics
Maternal employment status
Not working 48.33 59.51 52.20 63.06 49.91 58.67
1–34 hours per week 18.43 12.90 17.43 11.07 16.36 13.32
35 or more hours per week 33.23 27.59 30.37 25.87 33.73 28.01
Maternal race/ethnicity
White 15.96 21.31 24.97 18.92 22.04 20.91
Hispanic 48.20 58.92 48.13 63.95 47.09 58.11
Black 22.17 8.44 13.28 6.64 18.07 9.48
Asian/Pacific Islander 13.68 11.33 13.62 10.49 12.80 11.51
Maternal education
Less than high school (HS) 33.85 35.51 30.22 38.26 31.62 35.38
High school graduate 15.08 21.47 23.19 20.29 16.16 20.98
Beyond high school 29.20 26.12 25.14 26.70 29.76 26.36
College graduate or more 21.87 16.89 21.45 14.75 22.46 17.27
Family Background
Union status
Married 59.56 63.96 57.23 66.50 66.66 63.63
Not married and not cohabitating 16.38 19.21 20.93 17.54 23.61 19.00
Not married and cohabitating 24.06 16.83 21.85 15.96 9.74 17.37
Family income
<$5,000 28.74 23.66 20.79 25.91 22.61 24.04
$5,000–20,000 19.54 23.05 24.55 22.17 23.12 22.79
$20,000–40,000 10.11 20.87 16.11 21.29 22.62 20.06
>$40,000 41.61 32.42 38.54 30.63 31.66 33.11
N 57 807 225 580 59 864

Note. Unweighted Ns and weighted percentages are reported.

 BIRTH HEALTH AND CHILD CARE ARRANGEMENT 47

children without LBW (n D 807; 53% vs. 37%). About 24% of children with LBW received non-
relative care, 23% were in center care and 6% were cared for by a relative. More than 50% of
mothers with LBW babies were employed, as compared to 40% of mothers without LBW babies.
Approximately 22% of mothers with LBW babies were black, compared to less than 9% of
mothers with non-LBW babies. About one-fourth of mothers with LBW babies were unmarried
in a cohabiting relationship, compared to one-sixth of mothers without LBW. Distributions of
individual characteristics by subjective rating of child’s health at birth yielded patterns similar to
distributions by birth weight.
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Birth Weight and Child Care Arrangement

Table 2 presents the effect of birth weight on type of child care arrangement chosen using
multinomial logit regression models. Model 1 included only variables measuring birth weight,
child’s current health condition, and child’s age. Results show that mothers of LBW babies had
higher odds of using nonrelative care (Relative Risk Ratio [RRR] D 3.56; p  0:05) and center
care (RRR D 2.38; p  0:05) than parental care. Model 2 added maternal employment and
controlled for maternal SES and family background variables simultaneously. Mothers with LBW
babies still had higher odds of using nonrelative care (RRR D 3.57; p  0:05). As expected,
maternal employment was a significant predictor of using non-parental child care. Employed
mothers with LBW babies had higher odds of using any type of non-parental care, and working
more hours was associated with higher odds of using nonrelative care.
Our analyses also yielded significant differences between a child’s current health condition,
child’s age, racial/ethnic groups and maternal education in child care arrangement (Table 2).
Children with poorer current health had higher odds of using nonrelative care (RRR D 3.40,
p  0:05) and center care (RRR D 3.34; p  0:01) than parental care. The older the child, the
higher the odds of center care versus parental care (RRR D 6.74; p  0:01 for 1–2 years old;
RRR D 12.97; p  0:01 for 3–5 years old). Mothers with higher education were more likely
to use center care; Hispanics and Asians mothers were less likely to use center care than White
mothers. Single mothers had higher odds of using relative care (RRR D 2.74; p  0:05) and
nonrelative care (RRR D 4.24; p  0:01) than parental care.

Subjective Rating of Birth Health and Child Care Arrangement

Model 3 estimated the effect of subjective evaluation of birth health on subsequent child care
arrangement, adjusting for child’s current health condition and child’s age (Table 3). Results show
that mothers who rated their child’s birth health as better than other babies had higher odds
of using center care than mothers who rated their child’s birth health the same as other babies
(RRR D 2.01; p  0:05). Compared to mothers who rated their child’s birth health the same as
other babies, mothers who rated their child’s health at birth worse had higher odds of using non-
relative care (RRR D 2.54; p  0:10). Model 4 adjusted for the variable of maternal employment
and additional sociodemographic characteristics. Children with better perceived health at birth
still had higher odds of using center care (RRR D 1.92; p  0:10). Maternal employment is a
strong predictor of choosing non-parental care. Number of working hours increased the odds of
nonparental care use.
Controlling for child’s birth health and maternal employment, children who were older and
having poorer current health had higher odds of nonparental care use, particularly center-based
care. Hispanic, higher-educated, employed mothers were also more likely to use center care than
parental care when compared to their counterparts. Single, non-cohabiting mothers were more
likely to use relative and nonrelative care than married mothers.
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TABLE 2
Multinomial Logistic Regression Analysis of Relative Risk Ratios (RRR)a and 95% Confidence Interval (CI)a for

48
Types of Nonparental Child Careb by Birth Weight, L.A.FANS

Model 1 Model 2

Relative Care Nonrelative Care Center Care Relative Care Nonrelative Care Center Care

RRR 95% CI RRR 95% CI RRR 95% CI RRR 95% CI RRR 95% CI RRR 95% CI

Explanatory Variables
Birth health
Low birth weight
(Normal weight)
Yes 0.50* 0.10–2.46 3.56* 1.29–9.85 2.38*** 1.001–5.67 0.35*** 0.06–1.87 3.57*** 1.10–11.58 1.93*** 0.78–4.78
Maternal employment
Employment status of mothers
(Not working)
1–34 hours 7.52*** 3.09–18.27 7.08*** 2.86–17.53 6.12*** 2.08–18.00
35 or more hours 23.29*** 10.62–51.07 11.15*** 4.82–25.77 7.84*** 3.21–19.17
Controls
Child’s characteristics
Current health condition
(< 3 ear infections)
> 3 ear infections 0.81* 0.33–2.01 2.39* 1.09–5.23 2.55*** 1.37–4.75 1.07*** 0.37–3.08 3.40*** 1.33–8.68 3.34*** 1.66–6.72
Age of children (< 1 year)
1–2 years old 2.13* 1.01–4.46 1.86* 0.84–4.13 44.89*** 1.65–22.66 2.78*** 1.36–5.67 22.50*** 1.00–6.29 6.74*** 1.70–26.73
3–5 years old 1.54* 0.68–3.49 1.39* 0.64–3.01 10.57*** 2.71–41.20 1.67*** 0.76–3.65 1.45*** 0.64–3.27 12.97*** 3.12–53.88
Maternal SES characteristics
Maternal race/ethnicity (White)
Hispanic 0.45** 0.20–1.01 0.65*** 0.34–1.24 0.33*** 0.16–0.68
Black 0.54*** 0.12–2.48 0.40*** 0.12–1.39 0.81*** 0.30–2.17
Asian/Pacific Islander 1.76*** 0.73–4.27 0.45*** 0.14–1.44 0.32** 0.08–1.27
Education of mothers
(Less than HS)
High school graduate 0.50*** 0.20–1.24 0.79*** 0.34–1.81 0.85*** 0.35–2.08
Beyond high school 1.14*** 0.46–2.82 0.86*** 0.35–2.01 2.25* 0.90–5.63
College grad or more 0.42*** 0.14–1.23 1.44*** 0.58–3.56 1.67*** 0.58–4.79
Family background
Union status (Married)
Not married and not cohabiting 2.74*** 1.21–6.24 4.24*** 1.85–9.73 1.94*** 0.65–5.79
Cohabiting 1.22*** 0.58–2.54 0.73*** 0.27–1.95 0.52*** 0.18–1.54
Family income (< $5,000)
$5,000–20,000 0.73*** 0.29–1.80 0.75*** 0.32–1.77 1.22*** 0.50–2.97
$20,000–40,000 0.48** 0.22–1.05 0.92*** 0.35–2.40 0.68*** 0.28–1.64
> $40,000 0.54*** 0.21–1.37 1.79*** 0.68–4.73 1.24*** 0.55–2.78

a
Weighted multinomial logistic regression; standard errors adjusted for complex sample design.
b Reference group for outcomes is using parental care.
 p < 0:1. *p < 0:05. **p  0:01. ***p < 0:001.
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TABLE 3
Multinomial Logistic Regression Analysis of Relative Risk Ratios (RRR)a and 95% Confidence Interval (CI)a for
Types of Nonparental Child Careb by Subjective Rating of Birth Health, L.A.FANS

Model 3 Model 4

Relative Care Nonrelative Care Center Care Relative Care Nonrelative Care Center Care

RRR 95% CI RRR 95% CI RRR 95% CI RRR 95% CI RRR 95% CI RRR 95% CI

Explanatory Variables
Subjective rating of
birth health (Same)
Better 1.50* 0.78–2.89 1.30* 0.64–2.64 2.01*** 1.16–3.51 1.30*** 0.60–2.79 1.12*** 0.52–2.40 1.92** 0.95–3.91
Worse 0.69* 0.26–1.88 2.54 0.99–6.52 0.95*** 0.37–2.49 0.34*** 0.09–1.26 1.76*** 0.64–4.84 0.65*** 0.19–2.23
Maternal employment
Employment status of
mothers (Not working)
1–34 hours 7.52*** 2.93–19.27 6.57*** 2.55–16.96 6.10*** 2.16–17.19
35 or more hours 24.28*** 10.96–53.77 11.74*** 4.98–27.64 7.84*** 3.26–18.85
Controls
Child’s characteristics
Current health condition
(< 3 ear infections)
> 3 ear infections 0.80* 0.33–1.98 2.17 0.91–5.17 2.58*** 1.35–4.93 1.15*** 0.41–3.22 3.26*** 1.16–9.16 3.51*** 1.71–7.21
Age of Children (< 1 year)

1–2 years old 2.29* 1.07–4.91 1.76* 0.85–3.67 5.15*** 1.35–19.74 3.24*** 1.58–6.65 2.32 ** 0.99–5.43 7.31*** 1.90–28.10
3–5 years old 1.57* 0.70–3.55 1.38* 0.63–2.99 11.50*** 2.88–45.91 1.81*** 0.85–3.85 1.42*** 0.66–3.08 14.41*** 3.58–58.02
Maternal SES characteristics
Maternal race/ethnicity (White)
Hispanic 0.45** 0.20–0.99 0.71*** 0.38–1.34 0.35*** 0.18–0.67
Black 0.54*** 0.13–2.16 0.45*** 0.11–1.89 0.94*** 0.37–2.41
Asian/Pacific Islander 1.71*** 0.70–4.18 0.48*** 0.15–1.61 0.33*** 0.08–1.33
Education of mothers
(Less than HS)
High school graduate 0.53*** 0.20–1.36 0.75*** 0.32–1.78 0.81*** 0.32–2.03
Beyond high school 1.23*** 0.50–3.06 0.86*** 0.34–2.18 2.22** 0.90–5.50
College grad or more 0.42*** 0.14–1.26 1.45*** 0.61–3.43 1.54*** 0.53–4.47
Family background
Union status (Married)
Not married and not cohabiting 2.80*** 1.23–6.39 4.23*** 1.86–9.61 1.75*** 0.59–5.19
Cohabiting 1.27*** 0.64–2.54 0.88*** 0.28–2.73 0.46*** 0.16–1.36
Family income (ref  5,000)
$5,000–20,000 0.69*** 0.29–1.66 0.70*** 0.29–1.67 1.10*** 0.44–2.75
$20,000–40,000 0.53 ** 0.25–1.13 0.86*** 0.34–2.16 0.72*** 0.32–1.61
>$40,000 0.53*** 0.21–1.36 1.71*** 0.64–4.54 1.22*** 0.55–2.74

a
Weighted multinomial logistic regression; standard errors adjusted for complex sample design.
b
Reference group for outcomes is using parental care.

49

p < 0:1. *p < 0:05. **p  0:01. ***p < 0:001.
 50 C. CHIAO ET AL.

DISCUSSION

To our knowledge, this is the first effort to examine whether a mother’s perception of her child’s
perceived health at birth is related to subsequent child care arrangement choices, and how this
association is affected by maternal employment, after controlling for demographic characteristics,
maternal SES, and family variables. Mothers who perceive their children to be in poorer health
at birth (low birth weight and/or subjective rating birth health as worse than other babies) were
more likely to use nonrelative care than parental care in comparison to mothers with children in
better birth health, even when controlling for a child’s current health condition and his/her age.
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However, the association between birth health and child care arrangement chosen was also found
to be largely accounted for by maternal employment status with the exception of nonrelative care
use by mothers with LBW babies.
The considerable influence of employment status on child care arrangement regardless of child’s
birth health illustrates the importance of child care in balancing childrearing responsibilities with
work-related obligations as suggested by the work-family conflict model (Bianchi & Milkie,
2010; Goode, 1960; Kelly & Voydanoff, 1985; Warren & Johnson, 1995). While decisions to
work and use child care influence and interact with each other in complex ways (Han, 2004;
Hirst, 2002), results of the present study indicate that maternal employment largely explains the
association between perceived child’s birth health and subsequent child care arrangement decisions.
In addition, the results also support the construct of a mother’s “perceived susceptibility to illness”
for her child, as found in the Health Belief Model. Mothers who have LBW babies and/or in poor
health at birth may well decide to utilize licensed, professional child care in subsequent years. This
implies that these mothers expect their children to receive higher quality care from professionals
who are attuned to their possible medical needs.
Another noteworthy finding is that single mothers not in cohabiting relationships were signif-
icantly more likely to be using child care, especially relative and nonrelative care, than married
mothers, regardless of the child’s health at birth. Single, non-cohabiting mothers are more likely
to be working, and thus have a greater need for child care, given there is no partner to help with
financial and childrearing responsibilities (Hofferth, 1996; Hofferth et al., 1992; Uttal, 1999). In
our study, cohabiting mothers and married mothers were about equally likely to use nonparental
child care, suggesting that having a partner in the household influences child care decisions,
regardless of whether the mother is legally married or not.
Consistent with existing studies (Joesch et al., 2006), we found that the older the child, the
more likely they were to be receiving child care, regardless of birth health conditions. Parents
may choose to care for infants themselves because very young children are more vulnerable and
require more attention than older children, or because infant and toddler care is typically more
expensive than child care for older children. In addition to a child’s current health condition, our
results were consistent with existing epidemiological literature (Bradley, 2003; Lu et al., 2004)
that children enrolled in center care are more likely to contract infectious diseases, such as ear
infections, than children in parental care, when controlling for individual SES and other individual
characteristics.
In our analyses, we found that the significant LBW effect on the decision to use center care
decreased after adjusting for maternal SES and family background. These findings imply that
mothers with low birth weight babies may have received professional advice regarding infant
care and may therefore value professional or licensed types of child care, such as center or day
care, over other types. Mothers may also choose to place children who were born with low birth
weight in center care to generate a greater amount of peer interaction and structured activities
which, in turn, facilitate the child’s physical, social and cognitive development. Further research
is thus needed to investigate this association and how other indicators of child’s health at birth
are associated with care arrangements.
 BIRTH HEALTH AND CHILD CARE ARRANGEMENT 51

Results show that a higher percentage (22%) of mothers with LBW babies were Black, although
only 9% of the sample was Black; this result may slightly be influenced by the decision to exclude
Head Start participants .n D 23/ from the study’s sample. Minority mothers tend to use parental
care (Latino: 70%; Black: 52%; Asian: 54%) than Caucasian mothers (48%). Lack of child care
resources for children in poorer health may force parents to forego work and stay at home to
care for their children. Moreover, these disadvantaged families (i.e., minority, low income, non-
educated) are more likely to live in neighborhoods with an insufficient number of child care
resources, especially for children with health problems (Loeb et al., 2004; Neas & Mezey, 2003).
These families may thus be particularly vulnerable to higher environmental risk factors in their
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neighborhood, more stressful circumstances in their lives (e.g., unemployment, violence), fewer
sources of social support and more chronic health conditions (Kramer et al., 2001; Lu & Chen,
2004; Martin et al., 2002; Misra et al., 2000; Taylor et al., 1997; Votruba-Drzal et al., 2004).
The conclusions of this study are somewhat limited by the problem of endogeneity. To mitigate
this issue, we used the extensive data available in L.A.FANS to control for a wide range of
family characteristics that might influence both children’s health and child care decisions before
examining the effects of child’s birth health on subsequent child care choices. Further, the findings
are also constrained by several other limitations: (1) accuracy of the self-reported, subjective
evaluation by the mother of her child’s birth health, a retrospective measure potentially confounded
by recall bias; and (2) unmeasured traits and variables such as parenting style, personality and
attitudes toward a host of family-related issues and problems. The first (accuracy of the subjective
evaluation) was accounted for, to some degree, by the fact that our analysis of birth weight yielded
results that were very similar with respect to subsequent child care decisions. Both objective
and subjective aspects of birth health yielded similar estimates of their effects on child care
arrangements. It is certainly true, however, that unmeasured traits and variables may be influencing
the association between a child’s perceived health at birth and subsequent child care choices, even
though we controlled for major sociodemographic variables in the analysis.
This study provided insight into how a child’s birth health is associated with subsequent
child care decisions, which is largely explained by maternal employment, even after controlling
for a child’s characteristics, maternal SES, and family background. The findings underscore the
importance of child’s birth health conditions and maternal employment in relation to choices made
regarding childcare arrangements.
Recent initiatives in the United States to promote universal preschool and improvement of child
care quality in some states need to consider the special needs of children with health problems, as
well as problems parents may face in finding and affording appropriate child care. Given the need
for available and appropriate forms of nonparental child care remains a pressing concern for many
families, especially the disadvantaged, more research is needed on how child care decisions are
made, particularly for children with health or developmental problems. This includes additional
research on type, quality, cost and location of child care facility that parents choose. Research
in this area is necessary to inform federal, state, and county-level policy initiatives designed to
improve child care resources and address the specific child care needs of disadvantaged families
(Loeb et al., 2004; Love et al., 2003).

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